Provider Demographics
NPI:1073567186
Name:DEROVANESIAN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:DEROVANESIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160448
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33116-0448
Mailing Address - Country:US
Mailing Address - Phone:239-262-4519
Mailing Address - Fax:239-262-5672
Practice Address - Street 1:6400 DAVIS BLVD STE 103
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34104-5321
Practice Address - Country:US
Practice Address - Phone:239-775-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME26879207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78470OtherBC BS FL
FL067815500Medicaid
FL78470OtherBC BS FL
FL067815500Medicaid
930118917Medicare PIN
78470TMedicare PIN
P00196822Medicare PIN